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Objective: To examine the effects of including public health students on IPE teams on the interprofessional practice domain constructs (values/ethics, roles/responsibilities, interprofessional communication, and teams and teamwork).

Methods: This single-case, mixed-methods study was performed using a grounded theory approach. Students from 8 graduate health sciences programs participated in an asynchronous, 6-week, online IPE learning activity. Three of the 4 interprofessional practice domain constructs were examined as outcome variables: participants’ biomedical vs biopsychosocial patient approach (values/ethics); reported change in attitudes, beliefs, or values about other health professions (roles/responsibilities); and anticipated changes in future professional behaviors/interactions/approaches (teams and teamwork). Predictor variables were having an MPH participant on the IPE team, participants’ enrollment in a clinical or nonclinical program, and student perception of the online format (interprofessional communication).

Results: Three hundred nineteen students were included, 261 from clinical and 58 from nonclinical programs. A significant association was found between having an MPH participant on the IPE teams and participants’ awareness of the influence of social determinants of health (OR, 2.04; 95% CI, 1.13-3.66; P<.05). Program type was also significantly associated with awareness of the influence of social determinants of health, such that participants in nonclinical programs were significantly more likely to report the importance of social determinants of health in the care plan (OR, 3.68; 95% CI, 1.38-9.84; P<.01). Participants were significantly less likely to report future behavior change if they were in clinical programs (OR, 0.44; 95% CI, 0.23-0.86; P<.05) or if they disliked the online format (OR, 0.25; 95% CI, 0.14-0.42; P<.01). The model fit the data well (χ23=30.80; P<.001).

Conclusion: Inclusion of MPH students on IPE teams has the potential to increase clinical participants’ awareness of the influence of social determinants of health and interest in incorporating a biopsychosocial approach to health care.

eVideo. Interprofessional education prepares medical students to address social determinants of health and provide whole-patient care.

Interprofessional education (IPE) serves as a foundation for training health care professionals in the core competency domains of interprofessional practice (IPP): values/ethics, roles/responsibilities, interprofessional communication, and teams and teamwork.1,2 To prepare students in health profession programs for IPP, academic health centers should consider constituting IPE teams with students from various clinical and nonclinical programs so that team members can consider multiple perspectives, such as social determinants of health (SDOH), which are integral to successful community and population health initiatives.3,4

Social determinants of health include environmental, socioeconomic, demographic, and nonbiological variables that affect overall health and well-being.4 These determinants can be major factors in poor health, chronic disease, and costs to the health care system.5 The IPE program at Des Moines University integrates SDOH in health professions education6,7 and stimulates critical analysis of the traditional biomedical approach to care in favor of a biopsychosocial approach inherent in the Interprofessional Education Collaborative IPP domains.

Public health education programs are positioned to be strong allies for clinical health professions to integrate IPE within existing curricula.8-10 Bringing this perspective is not without its challenges.11-14 There is no single model of embedding public health into health professions curricula or IPE. Some medical schools have promoted concentration areas in public health,15,16 used case-based instruction, or included community service experiences as a part of core and elective curriculum.17,18 Others have created content areas in epidemiology, community partnerships, or emergency preparedness, and some have formed community partnerships.19-21 Klein et al22 found substantial changes in attitudes, knowledge, and practice behaviors of medical residents who received SDOH training compared with a control group that did not receive SDOH training. Bridges et al23 presented models of IPE that included interdisciplinary and experiential courses within curricula. Only 1 of the 3 universities included public health students.23 The IPE model presents a pedagogic approach to introduce or reinforce SDOH in clinically relevant contexts.24,25 This training may expand students’ points of view beyond a biomedical approach and increase awareness of SDOH.25 Substantial gaps in the peer-reviewed literature exist regarding educational outcomes when public health programs are included in IPE.26-30

The purpose of the current study was to examine the effect of master of public health (MPH) students in IPE teams on the acquisition of subsequent constructs related to IPP core competencies. We hypothesized that having an MPH participant on an IPE team would increase students’ recognition of the salience of SDOH in patient care (values/ethics), positively change their attitudes, beliefs, and values about other health professions (roles/responsibilities); and positively influence their anticipated future professional behavior (teams and teamwork). We also hypothesized that being from a nonclinical program and holding a negative perception of the online delivery of the learning activity could influence outcome variables.

Methods

This single-case, mixed-methods study using a grounded theory approach was performed in January 2013. The study was conducted at an academic health center and approved by the Des Moines University’s institutional review board.

Students enrolled in the spring 2013 university-wide IPE learning activity were included in the study but were permitted to opt out of the study or to have their submission removed from the aggregation of study data at their own request without prejudice. Students from clinical and nonclinical programs were assigned to virtual IPE teams to collaborate on an interprofessional care plan for a complex patient case. Graduate students from 8 academic programs were represented. All participants had an IPE scope of practice learning activity during their first year. The clinical programs represented were doctor of osteopathic medicine (DO), doctor of physical therapy (DPT), and doctor of podiatric medicine and surgery (DPM), all of which lead to professional licensure to deliver health care services. The nonclinical health programs represented were postprofessional doctor of physical therapy (PPDPT), MPH, master of health care administration (MHA), master of science in anatomy (MSA), and master of science in biological sciences (MSBS), none of which leads to clinical licensure. Participants were randomly assigned to 1 of 40 teams of 8 to 11 participants.

Design

Teams used an identical case of an older women of Hispanic descent whose personal and family circumstances could be interpreted as contributors to her acute and chronic comorbidities. Team communication was accomplished through Angel Learning, the university’s learning management system.

Faculty facilitators received standardized instructional materials and training and monitored discussion forum interactions. Teams selected a participant team leader to facilitate the discussion and completion of the interprofessional care plan. At the conclusion of 6 weeks, each team submitted their care plan, and each participant submitted a guided reflection paper.

Independent Variables

During the initial qualitative coding of narrative reflections, 3 unique themes emerged, which led to the definitions of the independent variables:

■ Team composition. Having an MPH participant on an IPE team could influence whether participants approached the patient from a biomedical vs a biopsychosocial orientation. For analysis, whether an MPH participant was assigned to a team was coded 0 (no MPH participant) or 1 (MPH participant).

■ Academic program influence. Clinical participants had not previously interacted with nonclinical participants in IPE learning activities at this institution. Because nonclinical participants other than MPH and MHA participants were also assigned to IPE teams, the authors agreed that being from a clinical vs a nonclinical program might potentially affect any or all of the outcome variables for 2 reasons. First, the nonclinical program curricula included online learning activities, and second, the participants from nonclinical programs would potentially not have been exposed to a biomedical approach to health care in the curricula to the same extent that clinical students may have been. For analysis, the participant’s respective educational program was coded 0 (clinical) or 1 (nonclinical) as operationally defined in the Design section.

The dependent variables were associated with IPP competency constructs through qualitative coding of the open-ended responses to questions in the guided reflection papers.

■ Roles/responsibilities. Participants were queried about their own and others’ roles and responsibilities by asking, “In what ways have your attitudes, beliefs, or values about other professions been changed, altered, or affirmed? Why?” Responses were coded as 0 (no change/negative change) or 1 (affirmed/positive change). “Affirmed” and positive “change” responses were grouped together based on the participants’ expression of “affirmed” and “change” in nearly identical language during the qualitative coding phase to indicate the likelihood of “change” in attitudes, beliefs, or values as a result of the IPE activity.

■ Values/ethics. To understand participants’ orientation to the patient, they were asked, “As you reflect on your learning in this module, what thoughts and feelings are engendered about the patient/client? Why? About other team members? Why?” The categorical coding of the biomedical model vs the biopsychosocial approach/awareness of the influence of SDOH was arrived at through qualitative analysis of the reflection papers and the participants’ focus on medical interventions as contrasted with comments about SDOH. Responses were coded 0 (biomedical model approach) or 1 (biopsychosocial approach/awareness of the influence of SDOH).

■ Teams and teamwork. This construct was assessed by asking, “How will your professional behaviors, interactions, and approaches change in your own work or future career as a result of what you have learned in this module? Why?” Responses were coded as 0 (no change/affirmed) or 1 (positive change). Positive change included specific references to consulting a public health professional, seeking resources outside one’s own profession to address SDOH, and recognition of patients who required an interprofessional approach for optimal health outcomes. “Affirmed” was grouped with “no change” during the initial qualitative coding, when it was observed that participants used “affirmed” in a similar or identical manner to responses expressing “no change.”

Data Analysis

The qualitative analysis was done to establish the quantitative coding schema. Two authors (P.A.D. and J.A.R.) used open-coding of key words and phrases and determined major themes, which were then agreed to by 2 different authors (T.A.S. and K.N.S.). The reflection papers were then analyzed using QDAMiner software (version 4, Provalis Research) to locate identified key phrases and references related to public health, MPH participants, and SDOH. The quantitative variables were posited through a nonexperimental design in which the qualitative responses to specific reflection questions were coded to represent categorical responses from the participants. Descriptive statistics, multicollinearity, likelihood ratios, and logistic regression were included in the quantitative analysis. The reference variable for all independent and dependent variables was 1.

All authors agreed to the coding scheme. The first and second authors coded the survey responses independently of each other and met to resolve disparate coding to achieve 100% interrater reliability. Noncongruence of coding occurred 12% of the time and was resolved by face-to-face meetings to review coding interpretations. All authors agreed in advance that if coding discrepancies could not be resolved, the third and fourth authors would weigh in to reach consensus. Unresolved discrepancies in coding did not occur in this study.

Analysis of the 319 participant responses were conducted with SPSS version 22 (IBM). Tests of multicollinearity were conducted using multiple linear regression before conducting hypothesis testing. There was no evidence of multicollinearity (variance inflation factor <1.1, tolerance values >0.9); each of the 3 predictor variables (MPH participant on the team, clinical vs nonclinical program, and view of online delivery) were included in a series of binary logistic regression analyses. Specifically, these predictor variables were regressed on the 3 IPP domain constructs of values/ethics, roles/responsibilities, and teams and teamwork.

Results

Of the 383 students recruited, 64 opted out of the study, leaving 319 participants who consented. There were 261 clinical students and 58 nonclinical students in the sample. Of the 40 teams, 16 teams (190 participants) included at least 1 MPH participant, representing 40% of all participants. The other nonclinical programs did not emerge as having significance from the qualitative coding and were therefore not included. Data analysis was adjusted to avoid potential skewing of results because of high DO program participation.

No significant association was found between having vs not having an MPH participant on the team or being in a clinical vs nonclinical program and participants’ attitudes, beliefs, and values regarding other professionals and professions (team and teamwork) (P>.4). There was a significant association, however, with attitudes toward the online delivery of the IPE activity such that greater dislike of the online delivery was associated with less change in anticipated future professional behaviors (OR, 0.15; 95% CI, 0.09-0.27; P<.001). The likelihood fit ratio indicated good model fit (χ23=52.12; P<.001) (Table 2).

Table 2.

Logistic Regression Analysis for Change in Attitudes, Beliefs, or Values Among Clinical and Nonclinical Health Program Participants on IPE Teams by Variable (N=319)

A significant association was found between having an MPH participant on the IPE teams and awareness of the influence of SDOH (OR, 2.04; 95% CI, 1.13-3.66; P<.05). A student’s academic program was also significantly associated with awareness of the influence of SDOH (OR, 3.68; 95% CI, 1.38-9.84; P<.01), such that students in nonclinical programs were significantly more likely to report the importance of SDOH in the care plan. Students’ attitude toward the online delivery was not significantly associated with awareness of the influence of SDOH (P>.08). The Likelihood ratio test indicated good model fit (χ23=20.72; P<.001) (Table 2).

Teams and Teamwork

Having an MPH participant on the IPE teams did not significantly influence participants’ anticipated future professional behavior (P>.05). Participants were significantly less likely to report future behavior change if they were in clinical programs (OR, 0.44; 95% CI, 0.23-0.86; P<.05) or disliked the online format (OR, 0.25; 95% CI, 0.14-0.42; P<.01). The model fit the data well (χ23=30.80; P<.001) (Table 2).

Independent Variables

Team Composition

Participant responses to questions about the patient were focused on either the health care interventions needed to address the medical diagnoses (biomedical approach) or SDOH observations (biopsychosocial approach). One participant wrote, “It was obvious how much the patient’s economic state affected her overall health status and ultimately landed her in the situation she is in today.”

Interprofessional Communication

Negative reactions toward the online delivery of the IPE learning activity often took the form of criticism of the activity design, stated preferences for face-to-face interactions, and resentment of the virtual learning environment because it created barriers to completing the assignment. Common expressions of lack of acceptance of the online format were similar to those of a student who said, “Working with a group online in this format is one of the most frustrating things I have done.”

Academic Program Influence

Many participants made particular note of the contributions of the nonclinical team members. For example, a participant said, “The biggest thing I learned was just how important the MPH and MHA participants are to the health care team…” Another person said, “A lot of people will write a [patient] off as noncompliant, but I think we need to dig deeper, which is why the MPH and MHA participants are so important to this team.”

Discussion

The findings of the current study demonstrate that the values/ethics IPE construct could be affected when MPH students are included on IPE teams. Teams with an MPH participant were 2 times as likely to report awareness of the influence of SDOH. Participants in nonclinical programs were more than 3.5 times as likely as clinical participants to report awareness of the influence of SDOH. The awareness of the need for a biopsychosocial orientation to a complex patient was statistically significant and may represent desired team composition for various IPE learning activities.

The biopsychosocial approach is directly tied to the first tenet of osteopathic medicine, which states that “The body is a unit; the person is a unit of body, mind, and spirit.”31 Without MPH participants’ input, some clinical participants may have overlooked aspects of SDOH in prioritizing the team responses regarding the interdisciplinary care plan. Being from a nonclinical program was associated with an increase in awareness of the influence of SDOH, potentially because these programs do not emphasize a biomedical approach to health to the extent that might be found in the curricula of clinical programs.

Having an MPH participant on the IPE team and coming from a nonclinical program were not associated with changes in attitudes, beliefs, or values about other health professions or anticipated changes in future professional behaviors. These results were most likely due to a ceiling effect because all participants had previously participated in an IPE activity that emphasized roles/responsibilities and teams and teamwork constructs.32 Of particular significance was the negative predictor of the online delivery format. Although the interprofessional communication domain subcompetencies encourage the use of technology as well as face-to-face interactions to improve communication, the online design of the IPE emerged as a problematic learning environment for some participants. The delivery via a web-based learning management system was necessary so that nonclinical participants who were off-campus could participate. In the future, a student orientation to the virtual learning environment may mitigate students’ negative perceptions of asynchronous online delivery.

Faculty and students received standardized instructions about their roles during the IPE learning activity. However, a limitation of this study might include variability of faculty involvement or student facilitation during the activity. Future research could investigate how facilitation methods in an online environment affect group dynamics and outcome variables. Specifically, it is possible that a dose-response relationship might be present.

This study was conducted at an academic health center with second-year graduate students. Therefore, the results may not be generalizable to IPE learning activities that include undergraduates or other clinical and nonclinical programs. In addition, the number of DO students ranged from 2 to 6 per team vs all other programs, which ranged from 0 to 2 per team, and, therefore, the findings may not be generalizable to IPE teams with balanced program representation. Team dynamics and interprofessional communication may have been influenced by overall team composition.33

Another limitation of this study was that we did not collect participant demographic information for analysis, such as age, sex, and race/ethnicity. Future research should analyze participant demographics to better understand the relationship these characteristics have with interprofessional competency domains and IPE learning outcomes. A final limitation in the number of nonclinical participants from the PPDPT, MHA, MSBS, and MSA programs, which did not permit an analysis of whether having a student from one of those programs on an IPE team would have resulted in similar results as were observed with having an MPH participant on the IPE team. Studies that examine various team interactions are worthwhile for further investigation.

Conclusion

The presence of public health students on IPE teams may have been instrumental in advancing team discussions about SDOH and its context for an individual patient.34,35 As educational programs prepare students for IPP, where primary care medical teams are accountable for community health outcomes, public health programs serve an important role in convening and shaping IPE implementation for clinical health professions programs.36 In light of the increased emphasis on population health found in the 2016 update to the IPE collaborative core competencies, academic health centers should seek opportunities to lead, collaborate, and participate in IPE activities with public health programs or agencies within their organization, in the community, and with other institutions.5,37-43

Acknowledgments

We acknowledge the contributions of Simon Geletta, PhD, for consultation on statistical analysis; Karen Render, for assistance with manuscript preparation; and Theresa White, DO, for research assistance in organizing data.